Swine Flu Ethics

A Jewish response to the potential swine flu pandemic.

They informed Rav Yehudah: There is a deadly plague affecting the pigs. He decreed a fast. Do we say that Rav Yehudah holds that a plague which affects one [animal] species is likely to affect all species (and therefore, kosher farm animals were threatened also)? No. Pigs are different since their digestive tracts are similar to those of humans. Babylonian Talmud, Taanis 21b

Since both pigs and humans lack a certain abdominal organ, there is reason to fear that epidemics that affect pigs may also particularly affect humans.

Meiri, Taanis 21b

Swine flu is only the most recent contagious epidemic to surface. History is replete with epidemics that swept the world, at times killing or seriously sickening significant portions of the population, and causing social and political upheaval. While there have been multiple world-wide pandemics in the last century (including the polio pandemic of the 1950s), several were not particularly severe. But in 1918, a world-wide influenza pandemic, known as "Spanish flu," killed between 20 and 40 million people, more than the number of people killed in World War One. In fact, more people died in one year of the Spanish flu than in the four years of the Black Plague (Bubonic Plague) pandemic that swept the world from 1347-1351.

It is not clear how severe the current Swine Flu outbreak will be. Sometimes the specter of widespread epidemic does not pan out, such as the frightening SARS outbreak in 2003 and the recent Avian Flu scare. Nevertheless, society must take precautions to protect itself from potential disaster. It is the protective measures which society utilizes that raise ethical questions. Many of these issues boil down to the conflict between individual autonomy and communal protection.

Judaism encourages policies which improve public health. While the Jewish approach to illness and healing requires us to recognize the paramount role of God in healing, we are obligated to guard our health by avoiding harmful activities and seeking appropriate medical care. [1] One is not even permitted to live in a city that does not have a doctor! [2]

What if someone does not agree to be quarantined?

Further, there is a Biblical obligation to return someone's health and a prohibition to "stand idly by" and allow one's neighbor to become harmed.[3] In fact, Maimonides, in his commentary on the Mishna, [4] teaches that the obligation of a physician to heal is derived from the Torah obligation to return a lost object. Maimonides explains that if one must return a lost object, he must surely return his friend's lost health! As a result, a physician is required to treat contagious patients after taking reasonable precautions to protect his health.

Even without a religious obligation, most people would probably want to cooperate with any governmental policies that would decrease the risk of spreading disease. But what if someone does not wish to cooperate? Does society have the right to limit their autonomy and coerce desirable action by mandating screening and treatment for serious contagious illnesses and breaching confidentiality to further public health goals?

For example, historically, when tuberculosis has posed a significant health risk, patients who did not voluntarily seek out treatment were forcibly institutionalized to receive treatment.[5] Even today, there are places in the United States that allow involuntary incarceration for tuberculosis treatment. The justification is that the untreated patient poses an unacceptable risk to others which justifies limiting his freedom. [6] Does Judaism accept this approach?

Autonomy versus Coercion

While there is a degree of patient autonomy in Jewish law, it is based on the idea that the patient is the final arbiter of what treatment is most prudent for his particular illness, based on his particular circumstances. Nevertheless, the patient is required to seek appropriate medical care and he may not refuse a standard and safe therapy that is documented to be effective, unless there is some other effective treatment. If the patient refuses an effective treatment for a dangerous condition, he may be coerced [7] to accept treatment unless the procedure or the stress of coercion poses an even greater risk to his health. [8]

It would follow that if the patient himself needs the treatment, particularly if the disease is life-threatening, then he is obligated to accept it and therefore society is justified in requiring it. But what if the threat to him is small, but the risk to others is great? Beyond the obligation to guard one's own health and to treat his neighbor's illness, there is an additional area of Jewish law that comes into play when it comes to public health.

The area of Jewish law called Choshen Mishpat, which deals with contracts and business, also spells out Torah based and rabbinic obligations that one has towards his fellow man to avoid causing damage. For instance, the Torah discusses the damages one must pay for digging a pit in a public place that may cause injury. The Talmud fleshes out this concept, with Jewish legal texts explaining that any action that creates a public safety threat is forbidden and creates liability on the part of the perpetrator. [9] This concept plays out in several ways in our current issue of epidemic and pandemic.

A person who carries a dangerous disease, even if he himself is not affected, is forbidden to act in a way that might spread the disease and must minimize danger to others. [10] Therefore, while confidentiality is a sacrosanct concept in Judaism and there is a strict prohibition against lashon hara (gossip) which prohibits revealing confidential information, a physician is obligated to inform the spouse of a patient with AIDS if the spouse will not give over the information himself. Similarly, if confidentiality will threaten public health, then public health must take precedence and information must be appropriately revealed.

Quarantine

Regarding quarantine, the issue is more complex. If a person has symptoms of the serious illness, it is easy to justify quarantine to protect the public. But, if a patient has only possibly been exposed to a serious contagious illness, are we justified in curtailing an individual's autonomy and freedom for a theoretical threat to public health?

The answer revolves around what represents pikuach nefesh (a threat to life). Jewish law requires pushing off all but three Torah prohibitions to save a life. Even for a questionable threat to life, Biblical prohibitions may be set aside. Rabbi Shlomo Zalman Aurbach, a leading Israeli posek of the 20th century, dealt with the question of how far this concept extends. He discussed immunization for a serious illness of which the general population is afraid. [11] If the vaccination is only offered on the Sabbath or one would have to wait several years to be immunized, foregoing the vaccination is considered a possible threat to life and justifies transgressing the Sabbath. [12] We see from this ruling that preventative health for an individual falls under the rubric of questionable threat to life.

Even those who do not display signs of flu are urged to remain in voluntary isolation for seven days.

A practical application of this concept is occurring with the current health crisis. The Israeli Health Ministry has ordered the quarantine of several people who have returned from Mexico and show signs of possible Swine Flu. Even those arriving from Mexico who do not display signs of flu are being urged to remain home in voluntary isolation for seven days, the incubation period of Swine Flu, until they are sure that no signs of the illness develop.

Two prominent poskim, Rabbi Yosef Sholom Elyashiv and Rabbi Shmuel Wosner, added halachic credence to the government's approach by ruling this week that yeshiva students who had recently returned from Mexico must be segregated from the other students until it is confirmed whether they have contracted Swine Flu. Rabbi Yosef Sholom Elyashiv, a leading rabbinic legal expert in Israel justified the quarantine, saying that "it could be a question of pikuach nefesh and until it is certain the students returning from Mexico are not infected, they should remain separate from the others."

Rabbi Wosner ruled that the students' school "must adhere to Health Ministry directives to keep the students separate." [13] Both of these rulings support quarantine in situations of public health concern, despite the inconvenience to the asymptomatic individuals.

It becomes clear that in times of epidemic, when weighing private rights versus societal obligations, society has a right to limit the autonomy of individuals if such limitations are reasonable and necessary for public health. Of course, such actions must be done in a way that limits inconvenience to the individual. Let us pray for a speedy and safe ending to the current medical crisis.

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About the Author

Dr. Daniel Eisenberg is with the Department of Radiology at the Albert Einstein Medical Center in Philadelphia, PA and an Assistant Professor of Diagnostic Imaging at Thomas Jefferson University School of Medicine. He has taught a Jewish medical ethics class for the past 15 years. Dr. Eisenberg writes extensively on topics of Judaism and medicine and lectures internationally on topics in Jewish medical ethics to groups of all backgrounds. Obtain more information on scheduling a lecture or learning more about Jewish medical ethics by visiting Dr. Eisenberg at www.daneisenberg.com

Visitor Comments: 5

Excellent sources, very logical and timely, and a pleasure to read. Thank you!

(3)
Gavriel Kleinerman,
May 4, 2009 3:30 AM

Dear Dr. Eisenberg,
I really enjoyed reading your article very much. Thank you for putting the energy necessary into writing it.
Perhaps you can tell would know why they are not able to find a vaccination for the swine flu being there are many people who have successfully weathered through the disease and recovered who have in their bodies the necessary antibodies to make a vaccination. Why is this not being done?
Thank you very much,
Gavriel

(2)
Rise,
May 3, 2009 8:41 PM

logical and important

(1)
rachel goldring,
May 3, 2009 4:44 PM

very imformative article and thanks for sharing

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I just got married and have an important question: Can we eat rice on Passover? My wife grew up eating it, and I did not. Is this just a matter of family tradition?

The Aish Rabbi Replies:

The Torah instructs a Jew not to eat (or even possess) chametz all seven days of Passover (Exodus 13:3). "Chametz" is defined as any of the five grains (wheat, spelt, barley, oats, and rye) that came into contact with water for more than 18 minutes. Chametz is a serious Torah prohibition, and for that reason we take extra protective measures on Passover to prevent any mistakes.

Hence the category of food called "kitniyot" (sometimes referred to generically as "legumes"). This includes rice, corn, soy beans, string beans, peas, lentils, peanuts, mustard, sesame seeds and poppy seeds. Even though kitniyot cannot technically become chametz, Ashkenazi Jews do not eat them on Passover. Why?

Products of kitniyot often appear like chametz products. For example, it can be hard to distinguish between rice flour (kitniyot) and wheat flour (chametz). Also, chametz grains may become inadvertently mixed together with kitniyot. Therefore, to prevent confusion, all kitniyot were prohibited.

In Jewish law, there is one important distinction between chametz and kitniyot. During Passover, it is forbidden to even have chametz in one's possession (hence the custom of "selling chametz"). Whereas it is permitted to own kitniyot during Passover and even to use it - not for eating - but for things like baby powder which contains cornstarch. Similarly, someone who is sick is allowed to take medicine containing kitniyot.

What about derivatives of kitniyot - e.g. corn oil, peanut oil, etc? This is a difference of opinion. Many will use kitniyot-based oils on Passover, while others are strict and only use olive or walnut oil.

Finally, there is one product called "quinoa" (pronounced "ken-wah" or "kin-o-ah") that is permitted on Passover even for Ashkenazim. Although it resembles a grain, it is technically a grass, and was never included in the prohibition against kitniyot. It is prepared like rice and has a very high protein content. (It's excellent in "cholent" stew!) In the United States and elsewhere, mainstream kosher supervision agencies certify it "Kosher for Passover" -- look for the label.

Interestingly, the Sefardi Jewish community does not have a prohibition against kitniyot. This creates the strange situation, for example, where one family could be eating rice on Passover - when their neighbors will not. So am I going to guess here that you are Ashkenazi and your wife is Sefardi. Am I right?

Yahrtzeit of Rabbi Moses ben Nachman (1194-1270), known as Nachmanides, and by the acronym of his name, Ramban. Born in Spain, he was a physician by trade, but was best-known for authoring brilliant commentaries on the Bible, Talmud, and philosophy. In 1263, King James of Spain authorized a disputation (religious debate) between Nachmanides and a Jewish convert to Christianity, Pablo Christiani. Nachmanides reluctantly agreed to take part, only after being assured by the king that he would have full freedom of expression. Nachmanides won the debate, which earned the king's respect and a prize of 300 gold coins. But this incensed the Church: Nachmanides was charged with blasphemy and he was forced to flee Spain. So at age 72, Nachmanides moved to Jerusalem. He was struck by the desolation in the Holy City -- there were so few Jews that he could not even find a minyan to pray. Nachmanides immediately set about rebuilding the Jewish community. The Ramban Synagogue stands today in Jerusalem's Old City, a living testimony to his efforts.

It's easy to be intimidated by mean people. See through their mask. Underneath is an insecure and unhappy person. They are alienated from others because they are alienated from themselves.

Have compassion for them. Not pity, not condemning, not fear, but compassion. Feel for their suffering. Identify with their core humanity. You might be able to influence them for the good. You might not. Either way your compassion frees you from their destructiveness. And if you would like to help them change, compassion gives you a chance to succeed.

It is the nature of a person to be influenced by his fellows and comrades (Rambam, Hil. De'os 6:1).

We can never escape the influence of our environment. Our life-style impacts upon us and, as if by osmosis, penetrates our skin and becomes part of us.

Our environment today is thoroughly computerized. Computer intelligence is no longer a science-fiction fantasy, but an everyday occurrence. Some computers can even carry out complete interviews. The computer asks questions, receives answers, interprets these answers, and uses its newly acquired information to ask new questions.

Still, while computers may be able to think, they cannot feel. The uniqueness of human beings is therefore no longer in their intellect, but in their emotions.

We must be extremely careful not to allow ourselves to become human computers that are devoid of feelings. Our culture is in danger of losing this essential aspect of humanity, remaining only with intellect. Because we communicate so much with unfeeling computers, we are in danger of becoming disconnected from our own feelings and oblivious to the feelings of others.

As we check in at our jobs, and the computer on our desk greets us with, "Good morning, Mr. Smith. Today is Wednesday, and here is the agenda for today," let us remember that this machine may indeed be brilliant, but it cannot laugh or cry. It cannot be happy if we succeed, or sad if we fail.

Today I shall...

try to remain a human being in every way - by keeping in touch with my own feelings and being sensitive to the feelings of others.

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